forms

Opt Out

Already have coverage?

Coordinating multiple plans: If you are an eligible student and have comparable coverage you may wish to coordinate your plans. Benefits under the two plans can be coordinated to increase your coverage up to 100% of the actual expense(s) incurred. For example, following payment under this plan you can submit outstanding balances to the other plan for consideration. Find out more about coordination of benefits.

Opting Out of coverage: If you are an eligible student and have comparable health and/or dental coverage you may apply to opt-out of the plan(s). Each student is given one opportunity to opt-out of the health and/or dental plan(s) each year.All opt-out forms must be completed online or through the Student Benefits Plan Office and must be received within 30 days from the start date of your full-time program. You will not be able to opt-out of coverage at any other point during the school year. NO EXCEPTIONS will be made if the deadline is missed. It is the student's responsibility to pay the plan fees, should they miss the applicable opt-out deadline.

Approval of your opt-out will result in the plan fee being credited. Once your opt-out has been accepted, it will remain in force as long as you remain an eligible student.

If you are unsure about whether or not you are eligible for the Student Health and Dental plan, please contact CCSS Member Service prior to any applicable deadlines.

Please read and agree to the Terms & Conditions prior to submitting your online opt-out.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Date of Birth

Date Month Field Date Day Field Date Year Field

Mailing Address

City

Province

Postal Code

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Required Direct Deposit Information

If YES, please enter your financial institution's Transit Number, Institution Number, and Account Number. (*mandatory fields)

** Please do not enter any dashes or spaces **

Transit #

Institution #

Account #

** Please do not enter any dashes or spaces **

Transit #

Institution #

Account #

Opt In

If a student has successfully completed an opt out but requires re-enrolment into the plan there are 2 opportunities to do so:

1) Upon Policy Anniversary: For students starting in September the anniversary would be the following September prior to the applicable deadline. For students starting in January the anniversary would be the following January prior to the applicable deadline.

2) Lifestyle Change: There are certain circumstances known as lifestyle changes that allow a student to make changes to their enrolment status within 30 days of the change. Lifestyle changes include; getting married or meeting the twelve month co-habitation requirement for common law status, birth/adoption of a child, meeting provincial plan residency requirements and losing their alternate coverage.

Students who lose their comparable coverage may opt back into the plan(s), provided that they are within 30 days of losing coverage. If a student has lost their comparable coverage they must show documentation of loss by submitting a letter from either the insurance carrier or employer.

Student Benefits Plan coverage is provided to eligible students automatically, except in certain circumstances where a student’s enrolment status excludes them from automatic inclusion by the institution or due to a previous waiver on file. To enroll in the Student Health and/or Dental plan(s), complete the sections below and submit this form. You will then be contacted by the CCSS Member Services, via an email notification, of any required supporting documents and fees. All supporting document(s) and fees must be received by the applicable deadline in order for the enrolment process to be completed.

Please read and agree to the Terms & Conditions prior to submitting your online Enrolment Form.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Gender

MaleFemale

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

The myBenefits Card is an important piece of identification that will ease access to your benefits. All eligible students must complete the myBenefits Card Registration Form. This multi-purpose card provides your policy information for submission of claims at both the Pharmacy and the Dental Office.

To obtain your myBenefits Card you must first register for BC Fair Pharmacare.

Downloading the myBenefits Card does not confirm eligibility or benefits coverage. Please contact the CCSS Member Services to confirm your enrolment in the plan.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Gender

MaleFemale

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

British Columbian Students - Please list your BC Fair PharmaCare Number
Out of Province Students - Please list your home province
International Students - Please list your country of residence

BC Fair PharmaCare Registration No.

Please indicate how you would like to access your benefits card

Please send an electronic version of myBenefits Card to the email address provide above
I will pick up my Benefits Card on Campus

Enrolment in the Student Health and Dental plan not guaranteed by submitting this form. The Student must be eligible for the program. Should you have any questions regarding the enrolment process please contact CCSS Member Services prior to submitting this form.

I understand the information provided above is required in order to obtain the said pay direct drug card. I hereby authorize and consent to the use, release, and exchange of the above information between the institution, the student organization, the Student Service Co-ordinator, Gallivan & Associates, BCE Emergis Assure Health Division, and the insurance carrier(s) to be used solely in connection with the Student Benefits Plan. I confirm that all the information provided herein is accurate. I also understand that the Student Service Coordinator may need to notify the institution to find out whether or not I have paid for the plan.

I Agree to the Terms & Conditions

Family Add On

2018 - 2019 Family Fees:
Health (one or more dependents) $130.00
Dental (one dependent) $175.00
Dental (two or more dependents) $250.00

Coverage provided through the Student Health and Dental plan can be extended to a spouse and/or dependent(s). To add eligible dependent(s) complete the sections below and submit this form. You will then be contacted by the CCSS Member Services, via an email notification, of any required supporting documents and fees. All supporting document(s) and fees must be received by the applicable deadline in order for the family add on process to be completed.

Please read and agree to the Terms & Conditions prior to submitting your online Family Add On form.